Novel approach to rectal foreign body extraction.

INTRODUCTION: The impacted rectal foreign body often poses a management challenge. Ideally, such objects are removed in the emergency department utilizing a combination of local anesthesia, sedation, minimal instrumentation, and manual extraction. In some instances, simple manual extraction is unsuccessful and general anesthesia may be necessary. We describe a novel approach to retrieval and removal of a rectal foreign body utilizing a SILS port. CASE DESCRIPTION: A 31-y-old male presented to the emergency department approximately 12 h after transanal insertion of a plastic cigar case. Abdominal examination revealed no evidence of peritonitis. On rectal examination, the tip of the cigar case was palpable. The foreign body, however, was unable to be removed manually in the emergency department. In the operating room, with the patient under general anesthesia, multiple attempts to remove the object were unsuccessful. A SILS port was inserted transanally. The rectum was then insufflated manually by attaching the diaphragm of the rigid sigmoidoscope to the SILS insufflation port. A 5-mm 0-degree laparoscope was placed through the SILS port. An atraumatic laparoscopic grasper was then placed through the port and used to grasp the visible end of the cigar case. The rectal foreign body was removed expeditiously. Direct visualization of the rectum revealed no evidence of mucosal injury. The patient was discharged home shortly after the procedure. DISCUSSION: The SILS port allows minimally invasive extraction of rectal foreign bodies not amenable to simple manual extraction. It provides excellent visualization and eliminates the morbidity inherent in more invasive and traditional methods of retrieval.

A cost-effective approach to establishing a surgical skills laboratory.

BACKGROUND: Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. METHODS: Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. RESULTS: Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982). CONCLUSIONS: Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources.

THE PPARgamma ligand 15d-PGJ2 modulates macrophage activation after injury in a murine trauma model.

In macrophages, peroxisome proliferator-activated receptor gamma (PPARgamma) has been shown to be important for differentiation, and it serves as a negative regulator of activation. Major trauma/injury causes a dramatic host response that disrupts cellular immune homeostasis and initiates an inflammatory cascade that predisposes the injured host to subsequent infections. In prior studies using a murine trauma model consisting of femur fracture and hemorrhage, splenic macrophages from traumatized mice had significantly enhanced LPS-induced cyclooxygenase enzyme (subtype 2) and iNOS production as well as elevated levels of inflammatory cytokines at 1 week after injury compared with uninjured controls. These up-regulated cellular responses corresponded to increased mortality when animals were challenged with LPS or Candida. In the current study, we used the injury model to determine the effect of treatment of injured mice with the endogenous PPARgamma ligand 15-deoxy-Delta(12-, 14)-PGJ2 (15d-PGJ2). It was found that in vivo 15d-PGJ2 treatment significantly reduced the levels of inflammatory mediators produced by splenic macrophages 7 days after injury. The mechanism of inhibition is dependent on PPARgamma because concomitant treatment of animals with the PPARgamma antagonist GW9662 reversed the inhibitory effect of 15d-PGJ2. Endogenous PPARgamma modulated activation of LPS-induced p38 mitogen-activated protein kinase. Furthermore, treatment of injured mice with 15d-PGJ2 conferred a significant survival advantage after infectious challenge induced by cecal ligation and puncture. Thus, this PPARgamma ligands significantly attenuate the postinjury inflammatory response and improve survival after infectious challenge.

Successful collaborative model for trauma skills training of surgical and emergency medicine residents in a laboratory setting.

OBJECTIVES: To determine whether interdepartmental educational and technical resources could be combined to successfully train surgery and emergency medicine residents in common diagnostic and therapeutic trauma skills outside the traditional hospital setting. DESIGN: Curriculum improvement survey. SETTING: Surgical Skills Laboratory, Temple University School of Medicine, Philadelphia, Pennsylvania. PARTICIPANTS: A total of 35 surgery residents (PGY 1 to 5) and 26 emergency medicine residents (PGY 1 to 3). METHODS: Emergency medicine attendings used human volunteers to train surgery residents in Focused Assessment with Sonography in Trauma (FAST). Trauma surgery attendings used a porcine model to teach emergency medicine residents tracheostomy, peripheral venous cutdown, diagnostic peritoneal lavage, tube thoracostomy, and bilateral thoracotomy. Upon completion of the courses, all residents were surveyed using a 5-point Likert scale to assess this teaching model. RESULTS: The percentage of residents reporting an improvement in knowledge levels after the course increased significantly (p < 0.003) for all skill modules (FAST, 14% vs 73%; tracheostomy, 20% vs 64%; peripheral venous cutdown, 25% vs 71%; diagnostic peritoneal lavage, 16% vs 60%; tube thoracostomy, 42% vs 92%; thoracotomy, 15% vs 42%). A significant (p < 0.05) increase in comfort levels during performance of the procedures in the clinical setting was also anticipated for all skills modules (FAST, 11% vs 60%; tracheostomy, 12% vs 50%; peripheral venous cutdown, 15% vs 31%; diagnostic peritoneal lavage, 12% vs 58%; tube thoracostomy, 35% vs 73%; thoracotomy, 0% vs 15%). PGY 1 to 4 surgery residents and PGY 1 and 2 emergency medicine residents perceived the greatest benefit (p < 0.05) from their respective courses. The overwhelming majority (89% to 100%) of surgery and emergency medicine residents felt the course was valuable and transferable to the clinical trauma setting. CONCLUSIONS: Interdepartmental collaboration between the Department of Surgery and Department of Emergency Medicine offered a unique training relationship that was a positive educational experience for all residents.